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vSAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued j_.Y=)7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct s <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District.i <br /> JOB ADDRESS/LOCATION ` I Wa0/ �l CENSUS TRACT <br /> Owner's Name �y�� _ Phone /76 <br /> Address 06 City <br /> Contractor's Name �� License �ro 2� Phone 3 <br /> TYPE OF WORK (Check) : NEW WELL I DEEPEN 1 / RECONDITION /7 DESTRUCTION F7 E <br /> PUMP INSTALLATION I f PUMP REPAIR 1 PUMP REPLACEMENT /7 r <br /> Other 1 I -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL � { <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> -.,.....Domestic/private Drilled Dia. of Well Casing <br />� Domestic/public Driven Gauge`ofT-Casing""''"" - <br /> Irrigation Gravel Pack -Depth of Grout Seal <br /> ._Cathodic Protection i Rotary Type of Gt'atit <br /> Disposal Other Other Information ; <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. /. L <br /> li PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR- /A*f' State Work Dane <br /> DES-TRUCTION OF,WELL: Well Diameter Approxi ate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District Y <br /> and the State of California pertaining to or regulating well •construction. Within FIFTEEN DAYS <br /> after completion of my work on- a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS PORT of the well and notify them before putting the..well in use. The above <br /> information �WGAND <br /> ue to the est of my. nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO AL INSPE ON. <br /> SIGNED L TITLE <br /> DRAW WOT PLAN ON REVERSE SIDE) � <br /> FOR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE �-� 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE Ii GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �(�3. ; DATE �I <br /> 9/76 2M <br /> E H 1426 Rev. 1-74 <br />